Retired headmaster dies due to cut of oxygen tube during treatment of Kovid

A retired headmaster who was undergoing treatment for coronavirus died after his oxygen tube was cut from his mask, an inquiry is heard. James Johnson, 83, of Wrexham was admitted to Wrexham Maelor Hospital on January 3, 2021.

Sadly, Mr Johnson, who was being treated for Covid pneumonia, died 10 days later in the hospital’s bony ward, where continuous positive airway pressure (CPAP) respiratory support was given during the pandemic. In the days following his death, Mr Johnson’s condition worsened and as of 12 January, a move to palliative care was being considered.

At the time of Mr Johnson’s death, the pandemic was in its third wave, which, according to Michelle Hughes, was the most difficult period for hospitals in North Meczyki. Ms Hughes, an interim surgical matron who was called to hospital aid in January 2021 due to being in a state of “extreme distress”, appeared as a witness at the interrogation at Ruthin County Hall via video link on Wednesday Gave.

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Interrogation heard Mr Johnson was receiving CPAP treatment along with three others at Bay Four in Bonnie Ward. There were four other CPAP patients in the ward at that time in two other divisions. Due to pandemic pressure, only two members of staff were tested to be able to access the bay.

Katherine Norgrove was one of two ward staff who were allowed into the bay and was on the opening shift on January 13. Mrs Norgrove told the court that it was best practice for a nurse to care for two patients in this ward, but on this day she and a health care support worker had to care for a total of eight patients – a situation where Which she described as “very disturbing” because she “could not reach every patient”.

When she herself was not inside the bay, Mrs Norgrove said it was possible to examine each patient’s monitor inside her through a large window. The monitors were turned to the window so that the saturation level for each patient could be viewed from outside the hallway. However, the window did not offer a full view of the tubes running from the CPAP machines to the masks worn by the patients.

To enter the bay, Mrs Norgrove would have to wear fresh PPE each time, and the process took about 30 minutes to complete, as heard in the interrogation. The nurse entered Bay Four to check on Mr Jones at around 10.30 a.m., at which time Mr Jones’s oxygen level was not a significant concern with the tubes fully attached to the CPAP machine from his mask.

Around noon, Mrs Norgrove had donned fresh PPE and went to Bay Three to help the patients with lunch – feeding them and checking their figures. The health care support worker who was working with him on the ward that day was doing the same to Mr Johnson at this time.

Mrs. Norgrove again left at around 1.30 pm at three o’clock. He told the court that he took off his PPE and prepared a round of medicine for Bay Four when he left Bay Three. At this point, she noticed that Mr. Jones’ saturation level had dropped and called a doctor to see Mr. Johnson.

The doctor noticed that the oxygen tube inserted in Mr Johnson’s CPAP mask was not connected and was pronounced dead at 2.10 pm. A postmortem was performed by Dr Muhammad Aslam, who provided the cause of death of Covid pneumonia with heart disease as a contributing factor.

An investigation conducted by the Betsy Cadwallad University Health Board found no other instance in which the oxygen tube from the CPAP machine was cut from the mask. As part of the investigation, the machine was tested and found to have no problems. Previous risk assessments considered using tape and glue to attach oxygen tubes to masks, but this was currently found to be ineffective with the least risky method, as heard in the inquiry.

The chairman of the inquiry told the court that tubing does not easily cut through the mask and that between 3 kg and 8 kg of pressure would be required to remove it. As such, the investigation made it unlikely that Mr Johnson had intentionally removed the tube because of his position at the time. The most likely cause, the investigation found, was that Mr Johnson leaned on the tube and caused the tube to become disconnected from the mask.

As part of lessons learned from the investigation into Mr Johnson’s death, a “tag in, tag out” system has been implemented to ensure that a member of staff is always present at Bonnie Ward. Auditing has taken place at Wrexham Maelor to ensure that learning is followed with some common themes from the test set to be implemented across the Board of Health.

John Gittins, Senior Coroner for North Meczyki East and Central, recorded the following narrative conclusion: “On 3 January 2021, the deceased was admitted to Wrexham Melor Hospital, where he was being treated for COVID pneumonia. As of 10 January he was In deteriorating condition she needed to receive treatment that included continuous positive airway pressure respiratory support and due to the pressure on the hospital arising out of the COVID pandemic, it was being delivered through a machine commonly used for home care. was done for

“Staffing pressure on 13 January 2021 meant that only two members of staff were tested, allowing them access to the room where Mr Johnson was caring for, and taking care of a total of eight patients. whereas a non-epidemic scenario for CPAP patients in optimal care would have ranged from one nurse to two patients.

“At around 1.30 a.m. on that date it was noted that Mr. Johnson’s saturation had decreased and the attending physician verified him dead at 2.10 p.m., after which it was noted that the oxygen tube inserted into the CPAP mask was no longer connected. It is not. It is possible to establish how the oxygen tube was clogged, although the lack of oxygen delivery to Mr. Johnson would have aggravated the hypoxia and it is possible that this may have accelerated his death.”

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